“When you change the way you look at things, The things you look at change.”
~ Wayne Dyer
T.236-989-0808
E. Info@awakelifesciences.com
First Name*
Last Name
Phone*
Email*
Address 1*
Address 2
City
Postal / Zip Code
Country
Province / State
Date of Birth*
Gender*
Marital status*
Emergency contact* Include name, phone number, email and your relationship to this person.
Session Details
What type of Session are you coming for?* Please select the service you are interested inCONSCIOUS Personal INPowerment sessionsCONSCIOUS Couple INPowerment sessionsCONSCIOUS Integration and support sessionsCONSCIOUS Peak performance and Self mastery sessionsCONSCIOUS Corporate Development consultation and support sessionsCONSCIOUS Interpersonal and corporate conflict resolution sessionsCONSCIOUS National and International AWAKE community gatheringsAwake Leadership institutes
Preferred date*
Healthcare Facility Admissions
Surgeries* Please list all surgeries including dates.
Treatment programs* Including detox, rehab and all other drug/alcohol treatment programs.
Other admissions* Including mental health hospitalizations and any other type of wellness program.
Physical Health History
Please select all that apply. If the condition is not listed, select 'other' to add it. If nothing applies, please select 'none'. Do you suffer from, or have ever been diagnosed with, any of the following
Digestive system issues* - Select -YesNo
Endocrine system issues* - Select -YesNo
General health issues* - Select -YesNo
Cardiovascular issues* - Select -YesNo
Immune system issues* - Select -YesNo
Nervous system issues* - Select -YesNo
Respiratory issues* - Select -YesNo
Muscle, bone & joint issues* - Select -YesNo
Kidney, bladder & reproduction issues* - Select -YesNo
Skin issues* - Select -YesNo
Physical health explanation ( Please describe any physical health conditions checked above. )
Mental Health History
Are you currently suicidal?* - Select -YesNo
If you are currently suicidal, please go to the nearest hospital or crisis center or contact your country's suicide hotline immediately.
Have you ever attempted suicide?* - Select -YesNo
Mental health conditions* - Select -YesNo
Mental health care* - Select -YesNo
If you are currently under the care of a mental healthcare professional, please describe. Otherwise, leave blank.
Drugs, Medications & Herbs
Drugs* - Select -YesNo
Are you currently using any of the following drugs on a regular basis?
Methadone/Suboxone* - Select -YesNo
Are you currently taking methadone or suboxone?
Methadone/Suboxone history* - Select -YesNo
Have you ever taken Methadone or Suboxone in the past?
Opioids* - Select -YesNo
Are you currently using any of the following opioids?
Benzodiazepines* - Select -YesNo
Are you currently taking any of the following benzodiazepines?
Antidepressants* - Select -YesNo
Are you currently taking any of the following antidepressant medications?
Mood stabilizers* - Select -YesNo
Are you currently taking any of the following mood-stabilizing medications?
ADD/ADHD medication* - Select -YesNo
Are you currently taking any of the following ADD/ADHD medication?
Marijuana* - Select -YesNo
Do you currently smoke marijuana on a regular basis?
Plants & psychedelics* - Select -YesNo
Do you have experience with any of the following plant medicines, psychedelics or psychoactive drugs?
Other medications & herbs* - Select -YesNo
Please list all other medications and supplements you are taking (including vitamins, herbs, inhalers, birth control pill, etc.) with dosage, frequency and reason for taking.
Health Habits
Exercise* - Select -ActiveVery ActiveExtremely Athletic Mild exercise
Daily meals* - Select -123More than 3 How many meals do you eat a day?
Nutrition* What is your diet like?
Medical diet* Are you on a diet? If yes, is it a physician prescribed medical diet? Please describe.
Dietary restrictions* - Select -YesNo
Please list any dietary restrictions you have.
Allergies* - Select -YesNo
Please list any allergies you have.
Salt intake* - Select -LowMediumHigh What is your average daily salt intake?
Sugar intake* - Select -LowMediumHigh What is your average daily sugar intake?
Caffeine* - Select -LowMediumHigh Do you drink any Caffeine?
Caffeine Drink Name* What is the name of caffeine drink?
Caffeine Intake* How many cups per day?
Alcohol* - Select -LowMediumHigh Do you drink alcohol?
Alcohol usage* What kind? How many drinks per week?
Alcohol addiction* - Select -YesNo Are you physically addicted to alcohol?
Alcohol cessation* - Select -YesNo Have you considered stopping drinking?
Blackouts* - Select -YesNo
Have you ever experienced blackouts while drinking?
Binging* - Select -YesNo
Are you prone to binge drinking?
DTs & shaking* - Select -YesNo
Do you suffer from DTs or shaking if you stop drinking?
Tobacco* - Select -YesNo
Do you use tobacco?
Personal History
Beliefs & practices* What are your personal beliefs and practices, if any?
Moral/spiritual upbringing* What were your and/or your family's spiritual beliefs and practices growing up, if any?
Life perspectives* How do you view yourself and others?
Where did you grow up?*
Childhood description* How would you describe your childhood and early family life?
Traumatic childhood?* - Select -YesNo
Would you say you had a traumatic childhood?
Sexual abuse Have you ever been sexually assaulted or abused?
Current home life* What is your current home life like? Who do you live with? Are the people you live with clean, sober and supportive?
Occupation* What is your occupation?
Typical day Please describe a typical day in your life.
Sleep patterns* How would you describe your sleep patterns? Do you have difficulty getting to sleep or staying asleep? Do you feel restless? How many hours of sleep do you get on average/night?
Coping skills* How do you usually handle emotional events and experiences?
Disappointments* What great disappointments have you experienced in your life?
Joys What great joys?*
Pride & enjoyment* What do you take pride in? What do you like doing? (If you are coming to us for addiction treatment - what do/did you enjoy doing when you are not/before you started, using?)
Addiction history* If you are coming to us for addiction treatment, have you gotten clean in the past? For how long and how did you do it?
Post-session* Do you have any particular requirements post session that need to be addressed?
Electronics* - Select -YesNo
Are you willing to be without electronic devices for the duration of your treatment? (Family members may reach AWAKE staff at anytime throughout the retreat).
After Session* - Select -YesNo
Are you willing to experience sleeplessness (depending on which medicine session you partake in) should it arise?
Life changes* - Select -YesNo
Are you ready for a change in your life?
Anything else?* Is there any other information we should know about you?
How did you hear about AWAKE Life Sciences?*
* By proceeding, accessing or using the Website and/or by booking a Session, you agree to comply with and to be bound by all of the terms and conditions described in the AWAKE life sciences NDA and terms of use policies. If you do not agree to all of these Terms, you are advised to not proceed to use the Website or book a Session as doing so you are knowingly proceeding, waiving all your alternative rights and you are agreeing with and to comply with and to be bound by all of the terms and conditions described by AWAKE.* By proceeding, accessing or using the Website and/or by booking a Session, you agree to comply with and to be bound by all of the terms and conditions described in the AWAKE life sciences NDA and terms of use policies. If you do not agree to all of these Terms, you are advised to not proceed to use the Website or book a Session as doing so you are knowingly proceeding, waiving all your alternative rights and you are agreeing with and to comply with and to be bound by all of the terms and conditions described by AWAKE.
* By proceeding forward, you have reviewed and agreed to the Awake Non-Disclosure and Safety Agreements* By proceeding forward, you have reviewed and agreed to the Awake Non-Disclosure and Safety Agreements
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